Friday, May 3, 2013

World Class

This is what can happen when a private practice surgeon refers a complicated colon cancer patient to a medical oncologist affiliated with a certain multinational, gigantic world-famous non-profit health care system.

Let's say the surgeon is asked to see a patient with a large bowel obstruction.  Perhaps the colonoscopy demonstrated a high grade constricting lesion in the distal sigmoid/upper rectum and the CT scan revealed a massive, locally infiltrating mass invading into the bladder and a possible liver lesion.  Perhaps the patient has lost 30 lbs recently and has noted foul smelling material in her urine.  The surgeon is concerned about diffuse tenderness on exam, possibly due to impending cecal ischemia.  He books the case for the OR and curbsides a med oncologist on treatment options.  Should I just divert?  Would there be a role for neoadjuvant chemoradiation?  Or best to just try and resect now with possible pelvic exenteration?  The med onc guy isn't too certain.  Whether there is liver involvement or carcinomatosis is key.  But no time to determine that now given presence of an acute abdomen.  He thinks the case ought to be presented to the tumor board and perhaps a multidisciplinarian consensus could emerge.  The surgeon thinks this seems reasonable.  He performs a laparoscopic diverting colostomy and places a mediport.  CT guided liver biopsy is scheduled as an outpatient.  She recovers from the surgery and is discharged home.  Her instructions are to follow up with a med oncologist from the world-famous healthcare conglomerate close to her house, in addition to seeing the surgeon. Arrangements are made for the case to be presented at next week's tumor board.  Patient's parting words to surgeon are: whatever you guys decide, I want you to do the surgery.  I trust you



Two weeks go by and the surgeon has not seen the patient in his office.  He doesn't see her name on any future appointment lists either.  No one answers the listed phone number.  His secretary tells him there is a Dr X on hold to discuss a patient.  Dr X is the original med onc guy he had curb-sided.  Dr X is energetically imperturbable and affable on the phone:

-Hey man, just wanted to give you an update on that one lady.
-OK.  Did you ever talk about her in the tumor board downtown?
-Um yeah.  She actually just had surgery.
-I'm sorry?
-Yeah, one of my colleagues saw her in the office.  At tumor board we agreed that if the liver mass was benign then surgery would be the initial move.
-She had surgery?
-Yeah, my colleague referred her to Dr Y.
-That's nice to know
-I guess they had to do some sort of modified exenteration procedure, partial bladder resection, hysterectomy...
-Good to know.  Good to know that when I refer patients to you guys that I will never see them again.
-Sorry man.  My colleague saw her.  He usually uses Dr Y for cases like that.  
-Yes.  Your colleague.  Thanks for the update.  I hope she does well.

Click.

These hypothetical situations can be rather discouraging....

14 comments:

Anonymous said...

"Call Public Relations and have them run the warm a fuzzy commercials, same day appointments cause every life deserves world class care". Good luck with that. The doctors who work at hospital world class actually believe they are special.

With that being said they do have some good docs over at the mega clinic. Many are assbarometers personally but as good as medicine can expect to offer otherwise.

Haywood J out

Anonymous said...

For some reason This reminds me of Nero in Ancient Rome who was oblivious when a fire was burning the kingdom to the ground? It's all world class, you can even see world class primary care physicians in Twinsburgh. Did Nero have a son?
Frank

Anonymous said...

My favorite is when they get an emergent complication after going to the megahospital. I wasn't good enough to do the original operation but I'm just fine to do the emergent complication.

Josh said...

So they attract all of the interesting elective work, and leave all of the rest of us in the community just serving as acute care ER specialists? Is that where this trend ends? Because despite my years of hard work and trainng, I cant possibly do a good job? By continuing to leach these cases it has many negative downstream effects: keeping community practices from growing, prevent new partners from beng hired and call duties from being shared more pleasantly, etc.. These big megahospitals seem to open tiny community hospitals (ERs really) as loss leaders to keep funneling cases to a few guys downtown far away from where patients live to a practice where NPs and PAs do the actual patient care. Just my observations on this issue (as usual, a good one to bring up).

Anonymous said...

Wait, so why did the patient go to the "megahospital" for her follow-up tumor board? Couldn't that be done at your hospital?

Also, with cases like these, aren't they usually done at more academic institutions, especially for pelvic exonterations? Would there have been a way for you to participate in this surgery even if they had called you back before the operation?

Anonymous said...

I understand your frustration but this is what healthcare is like now and it will never go back to the way it was years ago.i do not understand why you didn't perform the surgery.you are on staff at nearly all the major healthcare systems.. No matter what, we are very fortunate to have the world class care system in our city.we are very fortunate to have the 3 major systems we have in cleveland.cleveland clinic, metro, and uh all offer some of the best healthcare in the world.you are an excellent surgeon dr parks, be proud of that.

Anonymous said...

as for the first comment, the doctors at the mega hospital are special.so are the ones at uh and metro, etc.some doctors have bigger egos than others, so do some attorneys, etc. I don't care about their ego or their personality as much as their skills.it would be great to have a doctor with a great personality, lots of patience, and little ego, however, if I come in at 3am with a gunshot in my chest, just give me a skilled surgeon.

Anonymous said...

I hope patients read this blog and know, that you really do need a good doctor on your side to watch over you - protect you. Insist in writing that consults go to this person that you trust to help you sort things out.

The higher the probability of complex diagnostic and of multiple and complex surgical interventions and "high stay" (time in ICU) - the more you will find that you are a hot commodity. It's often because your illness means big money to the big networks, and they will tell you just about anything... to make you believe they "also care about you".

It's getting very nasty and dangerous out there.

-SCRN

Skyhigh said...

This is not an unusual situation. I remember a similar case from 5 years back when I lost two patients, one of carcinoma esophagus and other of carcinoma rectum.

Anonymous said...

I'm unclear--did the patient have carcinomatosis? If she had a peritoneal surface malignancy I thought there were only a small number of hospitals that specialize in tumor debulking and HIPEC in which case most community hospital -general surgeons would refer to a surgical oncologist who was proficient in that type of highly specialized treatment, and those (surgical specialists) are most likely to be found...at--> World Class Hospitals"

Jeffrey Parks MD said...

Anon-
No carcinomatosis. The definitive surgery could have been managed at suburban hospital.

Skeptical Scalpel said...

I echo one of the anonymous commenters above.

You can bet that when she gets her small bowel obstruction at 2 a.m., you will get the call from your ED.

Been there and done that many times.

PS: Unless everyone else in your town is incompetent, I wouldn't ever consult that oncologist again.

Anonymous said...

As a subspecialist I don't think a pt like this should be taken care of in a small hospital.

But it was handled poorly.

Jeffrey Parks MD said...

Anon-
Im at a suburban hospital not a small hospital. We have all the bells and whistles to complete a case like this. I agree, locally advanced rectal tumors probably ought to "go downtown". I personally wouldnt be comfy doing such cases. But this was a redundant sigmoid looped down into the back wall of the bladder. Urologists at my place were going to participate. The problem is that medical oncology is dominated by the flagship center, even in the community hospitals.